Failure to Prevent Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a CNA, resulting in a deficiency. On the date of the incident, the CNA approached the resident in an aggressive manner, pushed into the resident's abdominal and chest area with her stomach, and subsequently shoved the resident in the right arm and back, forcing her into the hallway. This interaction was captured on video, which was reviewed by facility leadership and surveyors. The video showed the CNA pulling a chair from the resident, the resident attempting to hit the CNA, and the CNA responding by physically pushing and shoving the resident multiple times. The resident involved had a history of dementia, schizoaffective disorder, diabetes, anxiety, major depressive disorder, and anemia, with moderately impaired cognition as indicated by a BIMS score of 10. The resident's care plan noted behavioral problems, including verbal and physical aggression, and included interventions for staff to use calm approaches and to remove the resident from situations as needed. Despite these interventions, the CNA engaged in a physical altercation with the resident rather than following the care plan's recommended strategies for de-escalation and redirection. Interviews with facility staff revealed that the CNA had previously reported feeling burnt out and had been in-serviced on abuse, neglect, and appropriate interventions for resident behaviors. The CNA admitted to being frustrated and acknowledged that she should have walked away from the situation. Facility leadership initially reassigned the CNA to another unit rather than removing her from resident contact, and did not immediately terminate her employment following the incident. The facility's policies required immediate removal of staff accused of abuse from resident contact pending investigation, but this was not followed in this case.
Removal Plan
- CNA A was placed on suspension pending termination by the Administrator.
- Director of Operations conducted re-education on Abuse and Neglect including recognizing, responding, and reporting abuse and neglect with the Administrator and Director of Nursing. Administrator and Director of Nursing voiced understanding of the re-education to the Director of Operations and signed the re-education.
- Resident #1 was assessed for signs and symptoms of physical abuse by the Director of Nursing with no negative findings. A progress note was charted.
- All residents that are able to be interviewed for any abuse and/or neglect event (no cognitive impairment) were interviewed by the Director of Nursing/Designee with no negative findings identified. A progress note was charted for each resident.
- All residents with cognitive impairment/not interviewable were assessed by the Director of Nursing/Designee for signs/symptoms of physical abuse with no negative findings. A progress note was charted for each resident.
- All staff were re-educated on abuse and neglect including recognizing, responding, and reporting abuse and neglect by the Administrator/Designee. Staff not present will be re-educated prior to the start of their next shift. Staff voiced understanding of the re-education to the Administrator/Designee and signed the re-education.
- The Medical Director of the center was notified of the immediate jeopardy event.
- The findings of this event will be presented to the center Quality Assurance Committee. An ad hoc Quality Assurance Committee meeting will be conducted.
- The Administrator/Designee will monitor/review incident reports and do random resident interviews during the work week to validate no resident abuse and/or neglect events have occurred.
- These audits will continue weekly for four weeks. Negative findings will be addressed at the time of discovery and presented to the center Quality Assurance Committee.